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ORIGINAL ARTICLE
Year : 2017  |  Volume : 36  |  Issue : 4  |  Page : 333-335

Pectoral fascia preservation during modified radical mastectomy: why and when


Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission24-Feb-2017
Date of Acceptance29-Mar-2017
Date of Web Publication13-Nov-2017

Correspondence Address:
Mohamed I Abdelhamid
El Shimaa St, EL Kawmia, Zagazig, Sharkia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejs.ejs_23_17

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  Abstract 

Context
The surgical treatment of breast cancer has changed significantly over time, but modified radical mastectomy (MRM) is still performed in about 20–30% of patients undergoing surgeries. Many articles that have studied the breast lymphatic system claim that the deep fascia is very poor in lymphatic vessels.
Aim
The aim of our study was to detect the benefits and oncological safety of pectoral fascia preservation in patients undergoing MRM.
Materials and methods
Totally, 73 patients with early breast cancer underwent MRM. The patients were randomized between removal (n=37) and preservation (n=36) of pectoral fascia.
Results
The amount of blood loss, operative time and drain output was significantly reduced in a case of pectoral fascia preservation (P>0.00001); in addition, seroma was significantly reduced (P=0.025). No chest wall recurrence had occurred in both groups.
Conclusion
Pectoral fascia preservation is safe and has many advantages as regards operative time, blood loss, seroma formation and cosmetic appearance of the flaps. It is oncologically safe compared with pectoral fascia resection, provided that good selection of the patient was done.

Keywords: breast cancer, pectoral fascia, pectoral fascia preservation


How to cite this article:
Abdelhamid MI, Alkilany MM, Lotfy M. Pectoral fascia preservation during modified radical mastectomy: why and when. Egypt J Surg 2017;36:333-5

How to cite this URL:
Abdelhamid MI, Alkilany MM, Lotfy M. Pectoral fascia preservation during modified radical mastectomy: why and when. Egypt J Surg [serial online] 2017 [cited 2017 Dec 17];36:333-5. Available from: http://www.ejs.eg.net/text.asp?2017/36/4/333/218156


  Introduction Top


Breast cancer is the most prevalent malignancy among women [1]. The surgical treatment of breast cancer has evolved from the radical mastectomy of Halsted to more limited surgery, which was introduced by Patey. In both techniques, pectoral fascia was resected to ensure radicality. Although breast conservation is considered the standard surgical approach for the treatment of early breast cancer patients, modified radical mastectomy (MRM) is still performed in about 30% of breast cancer patients [2],[3],[4].

Many articles that study the breast lymphatic system claim that the deep fascia is very poor in lymphatic vessels [5],[6].

Dalberg et al. [7] published the only study that compared pectoral fascia preservation and excision and concluded that there was no significant increase in local recurrence in the preservation group.

Da Silva et al. [8] studied the specimens from 30 cases of MRM in order to determine clinical and pathological factors that were associated with invasion of pectoral fascia and demonstrate that tumor–pectoral fascia distance was the only significant independent variable to predict pectoral fascia invasion.

The aim of our study was to detect the benefits and oncological safety of pectoral fascia preservation in patients undergoing MRM.


  Materials and methods Top


This prospective randomized control clinical trial was conducted at General Surgery Department, Zagazig University, between February 2013 and March 2014. Approved by local ethical committee of our faculty.

Totally, 96 patients were diagnosed with early breast cancer by complete history taking, clinical evaluation and full investigations and the diagnosis was proved histopathologically.

Informed consent was obtained from all patients.

Inclusion criteria

Female patients with early breast cancer and candidates for MRM were included in this study.

Exclusion criteria

The exclusion criteria were as follows:
  1. Stages III and IV breast cancer.
  2. Inflammatory breast cancer.
  3. Tumor very close to, or invading, the pectoral fascia.


Totally, 23 patients were excluded from the study, 14 refused participation, and nine had a deeply seated tumor. Seventy-three patients were included in the study and randomized into two groups: group I comprised patients (n=37) in whom the pectoral fascia was resected and group II comprised patients (n=36) in whom the pectoral fascia was preserved.

All patients underwent MRM with level II axillary dissection and closed with suction drain, which was removed when the amount of drain was between 20 and 30 ml/day.

Our patient received adjuvant chemotherapy protocols according to estrogen receptors (ER), progesterone receptors (PR), human epidermal growth factor receptor (HER2) and proliferation index (KI67).

All patients were followed up early postoperatively for drain output, seroma formation and cosmetic appearance of the flaps and late for recurrence.

All patients were followed up until January 2017(34–48 months), with a mean follow-up period of 41 months.


  Results Top


Totally, 73 patients were included in this study; the mean age of the patients was 55.9 years in group I and 57.4 years in group II. Tumor and patient features of our study are given in [Table 1].
Table 1 Demographic, clinical, and pathological features of patients in the study

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Intraoperative

The mean of intraoperative blood loss in group I was 300 ml, whereas it decreased significantly in group II to 198 ml (P=0.00001). As regards the operative time, it was about 80 min (mean) in group I and decreased significantly in group II to 59 min (P=0.00001), as shown in [Table 2].
Table 2 Intra-operative and post-operative characteristics of patients in the study

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Early postoperative

The volume of initial 7-day drain output was decreased significantly in group II, 501 ml, whereas in group I it was 791 ml (P=0.00001). As regards the duration of drains, in group I it was 15.3 days, whereas it decreased significantly in group II to 8.7 days (P=0.00001). Seroma occurred in nine patients in group I, whereas it occurred in only two patients in group II (P=0.025), as shown in [Table 2].

Pathological examination of excised pectoral fascia

Histopathological examination of pectoral fascia in group I (excised group) revealed negative deep pectoralis margin in all cases and tumor–pectoral fascia distance varied from 48 mm to 5 mm.

Long-term follow-up

The follow-up period of our patients was 34–48 months, with a mean follow-up period of 41 months. Our patients were followed up for chest wall recurrence by clinical examination and CA15-3. Breast ultrasonography, chest radiography and chest computed tomography were performed if there is suspected induration. No local recurrence occurred in both groups during this period, as shown in [Table 2].


  Discussion Top


Fisher stated that breast cancer is a systemic disease from the start and any change in local surgical management will have no effect on overall survival, and breast conservation is considered standard treatment for malignant breast diseases [9],[10].

Dalberg et al. [7] has published the only comparative study between preservation and resection of pectoral fascia. Therefore, we tried to focus on the benefit of pectoral fascia preservation and oncological safety.

In our study, many benefits for pectoral fascia preservation were observed as regards operative time, blood loss, drain output, seroma formation and cosmetic appearance of the flaps.

Subfascial plane also can be used for immediate reconstruction by breast implant and pectoral fascia provides more soft-tissue coverage [11].

All those benefits encourage preservation of pectoral fascia, but oncological safety is the most important point. Dalberg et al. [7] concluded that chest wall recurrence and overall survival are not significantly affected by preservation of pectoral fascia with long-term follow-up, but there is an increased risk for local recurrence of 1.8 among patients with fascia preservation.The most important risk factors for chest wall recurrence after MRM are deeply located tumor and excessive nodal spread [12],[13],[14]. Postoperative irradiation plays an important and significant role in controlling and decreasing the incidence of chest wall recurrence [15]. In our study, we excluded all patients with deeply seated tumor near the pectoral fascia, and this is may be the cause of absence of recurrence through the period of follow-up.

Pectoral fascia preservation is not mandatory in all cases, and choice of the patient is the most important factor; a tumor that is away from the pectoral fascia is less liable for local recurrence.


  Conclusion Top


Pectoral fascia preservation is safe and has many advantages as regards operative time, blood loss, seroma formation and cosmetic appearance of the skin flaps. It is oncologically safe as compared with pectoral fascia resection, provided that good selection of the patient was done.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Feuer E, Wun L, Boring C, Flanders WD, Timmel MJ, Tong T. The lifetime risk of developing breast cancer. J Natl Cancer Inst 1993; 85:892–897.  Back to cited text no. 1
    
2.
Patey D, Dyson W. The prognosis of carcinoma of the breast in relation to the type of operation performed. Br J Cancer 1948; 1:7–13.  Back to cited text no. 2
    
3.
Morrow M, Bucci C, Rademaker A. Medical contraindications are not a major factor in the underutilization of breast conserving therapy. J Am Coll Surg 1998; 186:269–274.  Back to cited text no. 3
    
4.
Baum M, Budzar A, Cuzick J, Forbes J, Houghton J, Klijn J. Anastrozole alone or in combination with tamoxifen versus tamoxifen alone for adjuvant treatment of postmenopausal women with early breast cancer: first results of the ATAC randomised trial. Lancet 2002; 359:2131–2139.  Back to cited text no. 4
    
5.
Zurrida S, Bassi F, Arnone P, Martella S, Del Castillo A, Martini R. The changing face of mastectomy (from mutilation to aid to breast reconstruction). Int J Surg Oncol 2011; 2011:7.  Back to cited text no. 5
    
6.
Gray J. The relation of lymphatic vessels to the spread of cancer. Br J Surg 1939; 26:462–495.  Back to cited text no. 6
    
7.
Dalberg K, Krawiec K, Sandelin K. Eleven-year follow-up of a randomized study of pectoral fascia preservation after mastectomy for early breast cancer. World J Surg 2010; 34:2539–2544.  Back to cited text no. 7
    
8.
Da Silva A, Rodrigues F, Lopes V. Oncological safety of pectoralis fascia preservation in modified radical mastectomies. Int J Cancer Res 2015; 49:1626–1630.  Back to cited text no. 8
    
9.
Fisher B. Breast cancer management − alternative to radical mastectomy. N Engl J Med 1979; 301:326–328.  Back to cited text no. 9
    
10.
Veronesi U, Cascinelli N, Mariani L. Twenty-year follow-up of randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002; 347:1227–1232.  Back to cited text no. 10
    
11.
Jinde L, Jianliang S, Xiaoping C, Xiaoyan T, Jiaqing L, Qun M. Anatomy and clinical significance of pectoral fascia. Plast Reconstr Surg 2006; 118:1557–1560.  Back to cited text no. 11
    
12.
Spratt J. Locally recurrent cancer after radical mastectomy. Cancer 1967; 20:1051–1053.  Back to cited text no. 12
    
13.
Donegan W, Perez-Meza C, Warson F. Biostatistical study of locally recurrent breast carcinoma. Surg Gynecol Obstet 1966; 122:1051–1053.  Back to cited text no. 13
    
14.
Valugassa P, Bonnadonna G, Veronesi U. Patterns of relapse and survival following radical mastectomy: analysis of 716 consecutive patients. Cancer 1978; 41:1170–1180.  Back to cited text no. 14
    
15.
Cuzick J, Stewart H, Peto R. Overview of randomized trials comparing radical mastectomy without radiotherapy against simple mastectomy with radiotherapy in breast cancer. Cancer Treat Rep 1987; 71:7–14.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2]



 

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